<!--COLUMN 1-->
		<div class="ThreeColGrid_c1">
		<img src="img/avatar.jpg" width="100" height="100" alt="Username">
		Add/change image
		</div>
	<!--COLUMN 1-->

	<!--COLUMN 2-->
	<div class="ThreeColGrid_c2">
		<form>
		<table border="0" cellspacing="0" cellpadding="0">
			<tr>
				<td valign="top">Username</td>
				<td><input name="" type="text"></td>
			</tr>
			<tr>
				<td valign="top">Salutation</td>
				<td>
					<select name="">
						<option value="Mr">Mr</option>
						<option value="Mrs">Mrs</option>
						<option value="Miss">Miss</option>
						<option value="Ms">Ms</option>
					</select>
				</td>
			</tr>
			<tr>
				<td valign="top">First name</td>
				<td><input name="" type="text"></td>
			</tr>
			<tr>
				<td valign="top">Last name</td>
				<td><input name="" type="text"></td>
			</tr>
			<tr>
				<td valign="top">Address</td>
				<td><textarea name="" cols="30" rows="5"></textarea></td>
			</tr>
			<tr>
				<td valign="top">County</td>
				<td>
					<select name="Counties">
						<optgroup label="England">
									<option>Bedfordshire</option>
									<option>Berkshire</option>
									<option>Bristol</option>
									<option>Buckinghamshire</option>
									<option>Cambridgeshire</option>
									<option>Cheshire</option>
									<option>City of London</option>
									<option>Cornwall</option>
									<option>Cumbria</option>
									<option>Derbyshire</option>
									<option>Devon</option>
									<option>Dorset</option>
									<option>Durham</option>
									<option>East Riding of Yorkshire</option>
									<option>East Sussex</option>
									<option>Essex</option>
									<option>Gloucestershire</option>
									<option>Greater London</option>
									<option>Greater Manchester</option>
									<option>Hampshire</option>
									<option>Herefordshire</option>
									<option>Hertfordshire</option>
									<option>Isle of Wight</option>
									<option>Kent</option>
									<option>Lancashire</option>
									<option>Leicestershire</option>
									<option>Lincolnshire</option>
									<option>Merseyside</option>
									<option>Norfolk</option>
									<option>North Yorkshire</option>
									<option>Northamptonshire</option>
									<option>Northumberland</option>
									<option>Nottinghamshire</option>
									<option>Oxfordshire</option>
									<option>Rutland</option>
									<option>Shropshire</option>
									<option>Somerset</option>
									<option>South Yorkshire</option>
									<option>Staffordshire</option>
									<option>Suffolk</option>
									<option>Surrey</option>
									<option>Tyne and Wear</option>
									<option>Warwickshire</option>
									<option>West Midlands</option>
									<option>West Sussex</option>
									<option>West Yorkshire</option>
									<option>Wiltshire</option>
									<option>Worcestershire</option>
						</optgroup>
						<optgroup label="Scotland">
									<option>Aberdeenshire</option>
									<option>Angus</option>
									<option>Argyllshire</option>
									<option>Ayrshire</option>
									<option>Banffshire</option>
									<option>Berwickshire</option>
									<option>Buteshire</option>
									<option>Cromartyshire</option>
									<option>Caithness</option>
									<option>Clackmannanshire</option>
									<option>Dumfriesshire</option>
									<option>Dunbartonshire</option>
									<option>East Lothian</option>
									<option>Fife</option>
									<option>Inverness-shire</option>
									<option>Kincardineshire</option>
									<option>Kinross</option>
									<option>Kirkcudbrightshire</option>
									<option>Lanarkshire</option>
									<option>Midlothian</option>
									<option>Morayshire</option>
									<option>Nairnshire</option>
									<option>Orkney</option>
									<option>Peeblesshire</option>
									<option>Perthshire</option>
									<option>Renfrewshire</option>
									<option>Ross-shire</option>
									<option>Roxburghshire</option>
									<option>Selkirkshire</option>
									<option>Shetland</option>
									<option>Stirlingshire</option>
									<option>Sutherland</option>
									<option>West Lothian</option>
									<option>Wigtownshire</option>
						</optgroup>
						<optgroup label="Wales">
									<option>Anglesey</option>
									<option>Brecknockshire</option>
									<option>Caernarfonshire</option>
									<option>Carmarthenshire</option>
									<option>Cardiganshire</option>
									<option>Denbighshire</option>
									<option>Flintshire</option>
									<option>Glamorgan</option>
									<option>Merioneth</option>
									<option>Monmouthshire</option>
									<option>Montgomeryshire</option>
									<option>Pembrokeshire</option>
									<option>Radnorshire</option>
						</optgroup>
						<optgroup label="Northern Ireland">
									<option>Antrim</option>
									<option>Armagh</option>
									<option>Down</option>
									<option>Fermanagh</option>
									<option>Londonderry</option>
									<option>Tyrone</option>
						</optgroup>
					</select>
				</td>
			</tr>
			<tr>
				<td valign="top">Postcode</td>
				<td><input name="" type="text"></td>
			</tr>
			<tr>
				<td valign="top">Email</td>
				<td><input name="" type="text"></td>
			</tr>
			<tr>
				<td valign="top">Telephone</td>
				<td><input name="" type="text"></td>
			</tr>
			<tr>
				<td valign="top">Fax</td>
				<td><input name="" type="text"></td>
			</tr>
			<tr>
				<td valign="top">Match member since</td>
				<td>00-00-00</td>
			</tr>
			<tr>
				<td valign="top">Last logged in</td>
				<td>00-00-00</td>
			</tr>
			<tr>
				<td valign="top">GPHC Number</td>
				<td><input name="" type="text"></td>
			</tr>
			<tr>
				<td valign="top">Date of pharmacist registration</td>
				<td><input name="" type="text"></td>
			</tr>
			<tr>
				<td valign="top">IT compatibility</td>
				<td>
					<select name="">
						<option>Link</option>
						<option>Nexphase</option>
						<option>QicScript</option>
						<option>Pharmasys</option>
						<option>Analyst PMR</option>
						<option>Proscript</option>
						<option>Ascribe</option>
						<option>Smartscipt</option>
						<option>Pharmacy Manager</option>
						<option>Link Evolution</option>
						<option>Compass</option>
						<option>Mediphase</option>
					</select>  
				</td>
			</tr>
			<tr>
				<td valign="top">EPS1 ready</td>
				<td>Yes <input name="" type="checkbox" value=""></td>
			</tr>
			<tr>
				<td valign="top">EPS2 ready</td>
				<td valign="top">Yes <input name="" type="checkbox" value=""></td>
			</tr>
			<tr>
				<td valign="top">Essential services</td>
				<td>
					<select name="" multiple>
						<option value=\"Dispensing of medicines">Dispensing of medicines</option>
						<option value=\"Repeat Dispensing">Repeat Dispensing</option>
						<option value=\"Stomach &amp; Incontinence Services">Stomach &amp; Incontinence Services</option>
						<option value=\"Waste Management">Waste Management</option>
						<option value=\"Public Health">Public Health</option>
						<option value=\"Signposting">Signposting</option>
						<option value=\"Support for self care">Support for self care</option>
						<option value=\"Induction in clinical governance">Induction in clinical governance</option> 
					</select>
				</td>
			</tr>
			<tr>
				<td valign="top">Advanced services</td>
				<td>
					<select name="" multiple>
					<option value=\"MUR &amp; Prescription Intervention Service">MUR &amp; Prescription Intervention Service</option>
					<option value=\"Appliance Use Review Service (AUR)">Appliance Use Review Service (AUR)</option>
					<option value=\"Stoma Appliance Customization (SAC)">Stoma Appliance Customization (SAC)</option>
					<option value=\"New Medicine Service (NMS)">New Medicine Service (NMS)</option>
					</select>
				</td>
			</tr>
			<tr>
				<td valign="top">Enhanced services</td>
				<td>
					<select name="" multiple>
						<option value=\"Supervised Adminstration">Supervised Adminstration</option>
						<option value=\"Needle &amp; Syringe Exchange">Needle &amp; Syringe Exchange</option>
						<option value=\"Stop Smoking">Stop Smoking</option>
						<option value=\"Care Home (Support &amp; advice)">Care Home (Support &amp; advice)</option>
						<option value=\"Medicines Assessment &amp; Compliance Support">Medicines Assessment &amp; Compliance Support</option>
						<option value=\"Medication Review (full clinical review)">Medication Review (full clinical review)</option>
						<option value=\"Minor Ailment Scheme">Minor Ailment Scheme</option>
						<option value=\"Out of Hours (access to medicines)">Out of Hours (access to medicines)</option>
						<option value=\"Supplementary Prescribing by pharmacists">Supplementary Prescribing by pharmacists</option>
						<option value=\"Emergency Hormonal Contraception (EHC)">Emergency Hormonal Contraception (EHC)</option>
						<option value=\"Seasonal Influenza Vaccinations">Seasonal Influenza Vaccinations</option>
						<option value=\"Chlamydia Screening &amp; Treatment">Chlamydia Screening &amp; Treatment</option>
						<option value=\"NHS Health Check (Vascular Risk Assessment &amp; Management Service)">NHS Health Check (Vascular Risk Assessment &amp; Management Service)</option>
						<option value=\"Weight Management (Child)">Weight Management (Child)</option>
						<option value=\"Weight Management (Adult)">Weight Management (Adult)</option>
						<option value=\"Alcohol Screening &amp; Brief Intervention">Alcohol Screening &amp; Brief Intervention</option>
						<option value=\"Anticoagulant Management">Anticoagulant Management</option>
						<option value=\"Independent Prescribing">Independent Prescribing</option>
						<option value=\"Sharps Disposal">Sharps Disposal</option>
						<option value=\"Emergency Supply (NHS expense)">Emergency Supply (NHS expense)</option>
					</select>
				</td>
			</tr>
			<tr>
				<td valign="top">Patient Group Directives</td>
				<td>
				<textarea name="" cols="30" rows="5"></textarea>
				</td>
			</tr>
			<tr>
				<td valign="top">Unavailable dates</td>
				<td><img style="margin: 0 0 20px 0;" src="img/cal.jpg" width="195" height="192" alt="calendar"></td>
			</tr>
			<tr>
				<td>&nbsp;</td>
				<td>&nbsp;</td>
			</tr>
		</table>

		</form>
	</div>
	<!--COLUMN 2-->

	<!--COLUMN 3-->
	<div class="ThreeColGrid_c3"></div>
	<!--COLUMN 3-->